Article Text

Impact of a demand-side integrated WASH and nutrition community-based care group intervention on behavioural change: a randomised controlled trial in western Kenya
  1. Matthew C Freeman1,2,
  2. Anna S Ellis1,
  3. Emily Awino Ogutu2,
  4. Bethany A Caruso2,
  5. Molly Linabarger2,
  6. Katie Micek1,
  7. Richard Muga3,
  8. Amy Webb Girard2,
  9. Breanna K Wodnik2,
  10. Kimberly Jacob Arriola4
  1. 1Gangarosa Department of Environmental Health, Emory University, Atlanta, Georgia, USA
  2. 2Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
  3. 3Faculty of Health Sciences, Uzima University, Kisumu, Kenya
  4. 4Department of Behavioral, Social, and Health Education Sciences, Emory University, Atlanta, Georgia, USA
  1. Correspondence to Dr Matthew C Freeman; matthew.freeman{at}


Introduction Growth shortfalls and diarrhoeal diseases remain a major cause of morbidity and mortality in low-income settings. Due to the multifaceted causes of undernutrition and the identified limitations of siloed nutrition programmes, improving the delivery of integrated water, sanitation, hygiene (WASH) and nutrition programming could improve child health.

Methods We conducted a cluster randomised trial in western Kenya to assess the impact on household behaviours of a novel, theory-informed and integrated WASH and nutrition intervention delivered through care groups as compared with the standard care group approach. We developed an intervention targeting practices relating to food hygiene, mealtime and feeding, and compound cleanliness, each using various behavioural change techniques to influence the uptake of targeted behaviours. Prespecified behavioural outcomes were verified through direct observation, 24 hours recall, and self-reported picture-based methods.

Results Compared with control households, a greater proportion of intervention households had a hygienic food preparation area (Risk double difference (RDD) 0.81, 95% CI 0.68 to 0.96), had stored food hygienically (RDD 0.76, 95% CI 0.58 to 1.00), had a functional handwashing station (RDD 0.64, 95% CI 0.56 to 0.74), provided a safe space for their child to play (RDD 0.73, 95% CI 0.56 to 0.96), and who fed their children thickened porridge (RDD 0.56, 95% CI 0.51 to 0.63) at endline. The proportion of children 6–24 months in intervention households consuming a sufficient diversity of foods (RDD 0.81, 95% CI 0.64 to 1.04) was higher than in control households; however, there was a non-significant increase in the percentage of pregnant and lactating women receiving an adequate diversity of foods in their diets (RDD 0.86, 95% CI 0.70 to 1.05) among intervention compared with control households at endline.

Conclusion Our integrated WASH and nutrition intervention resulted in important changes in behaviours. This theory-informed intervention could be added to existing care group programmes to considerable advantage.

  • nutrition
  • environmental health
  • stunting
  • cluster randomized trial
  • hygiene

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  • Handling editor Soumitra S Bhuyan

  • Twitter @Caruso_Bethany, @BreannaWodnik

  • Contributors MCF conceived of the study; MCF, AE, BAC, EO, RM, KJA, AWG designed the study; EO, AE, RM managed data collection with BKW, KM, and ML; MCF, KM, ML, and BKW conducted data analysis; MCF wrote the first draft; All authors reviewed and provided edits.

  • Funding Catholic Relief Services was the main implementing partner and funded the study.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Emory University Institutional Review Board (Atlanta, GA USA) (#IRB00090057), as well the National Commission for Science, Technology and Innovation (NACOSTI) and the Great Lakes University of Kisumu Ethical Review Boards in Kenya.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. All relevant data and corresponding code will be uploaded for open access once paper is accepted.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.